Recovery and change: Psychology's role in treating and preventing child sexual abuse

This special issue of InPsych focuses on the topic of child sexual abuse (CSA), and it is timely. In recent years, greater public attention has been paid to CSA, in particular, the Royal Commission into Institutional Responses to Child Sexual Abuse was instrumental in building awareness about the scope of the problem. This overview looks at the contribution of psychology to the prevention and treatment of CSA. By examining the definitions, prevalence, context and patterns of behaviour, I will identify some of the key issues for psychology and psychologists.

As psychologists, we have a duty to make it clear to the public and our clients the extent and impact of CSA, and the importance of prevention and treatment. We need to model non-judgemental, measured, sensitive responses to reports of offences and offending behaviour. For example, it helps me to speak in a professional way in conversations, or while giving presentations, and to keep in mind that a number of people listening may have experienced CSA or be offenders wanting to seek help. It is also important to differentiate the behaviour from the human who does it. I learned, for example, while working in the prison system, to stop using the term ‘murderer’ or ‘rapist’, and instead say ‘someone who has committed murder or rape.’

Public understanding of the issue

The public’s perception of CSA is largely taken from television shows, sensational media coverage of extreme and horrific offending, and punitive comments made in general conversation or on radio talkback. There may be a perception that not using condemning terminology implies condoning the offending, or being lenient or biased towards offenders. People also use the term ‘paedophile’ inappropriately regardless of its actual meaning. The terms ‘child sexual offender’ and ‘paedophile’ are not synonymous.¹ The use of stigmatising and vilifying language in the media may actually deter people from recognising or admitting they have a problem, or coming forward for help.

A truer picture

The reality of CSA is a far cry from the picture garnered from media. The entire topic resembles an iceberg with only the top 10 per cent visible and the remaining 90 per cent hidden below the surface. The majority of CSA goes unreported to the criminal justice system, child protection agencies or anyone at all. For example, the Dunkelfeld (Dark Field) Project (see article Child sexual abuse as a global challenge in this special issue) is named in recognition that most sexual offending occurs in darkness and rarely comes to light. Given the hidden nature of CSA, it is difficult to access comprehensive statistics about the true scope of the problem.

A major reason for this is that most sexual abuse occurs within families (intrafamilial CSA), and many victims may never disclose the abuse. Retrospective studies, where adults report childhood experiences of abuse, is one way we know how prevalent child sexual abuse is and that a great proportion of it is intrafamilial (Quadara et al., 2015).

Definition of CSA

The emphasis on institutional and extrafamilial CSA in Australia has exposed the even greater problem experienced by so many people in our community – that abuse mostly occurs within families. As stopitnow.org outlines:

All sexual touching between an adult and a child is sexual abuse. Sexual touching between children can also be sexual abuse when there is a significant age difference (often defined as three or more years) between the children or if the children are very different developmentally or size-wise. Sexual abuse does not have to involve penetration, force, pain or even touching. If an adult engages in any sexual behaviour (looking, showing or touching) with a child to meet the adult’s interest or sexual needs, it is sexual abuse. This includes the manufacture, distribution and viewing of child pornography, now called child sexual abuse material (CSAM). (In Australia, it is called CEM – child exploitation material).

They explain CSA is not necessarily defined by a single instance of abuse, and is often a gradual process with a series of early-warning signs and behaviours that, if identified, could help people intervene and stop the abuse before it starts, and before a child is harmed. Accordingly, it is adults who are responsible for stopping the sexual abuse of children by being vigilant, and calling out problematic, red-flag behaviour that risks child safety.

Prevalence

The Royal Commission into Institutional Responses to Child Sexual Abuse was limited by its terms of reference to institutional abuse and did not relate to the 90% of unknown or intrafamilial offending. The aforementioned iceberg analogy means we cannot necessarily see the true scope of the problem, and the statistics reported are often a conservative estimate of the actual rates of CSA in the community:

• Girls: 1 in 4 sexually abused before the age of 18
• Boys: 1 in 8 sexually abused before the age of 18
• More than 80% of CSA occurs within family network
• 30–60% of sexual abuse of children is enacted by adolescent children (usually boys in the family network) (AIFS, 2017; Cashmore & Shackel, 2013; El Murr, 2017; Russell, 1986; Ryan, 2011).

Another international definition and perspective of intrafamilial child sexual abuse, the Centre of Expertise on Child Sexual Abuse (CSA Centre) states:

Intrafamilial child sexual abuse refers to child sexual abuse (CSA) that occurs within a family environment. Perpetrators may or may not be related to the child. The key consideration is whether the abuser feels like family from the child’s point of view. Around two-thirds of all CSA reported to the police is perpetrated by a family member or someone close to the child. Where research has recorded the gender of perpetrators of intrafamilial CSA, the vast majority have been found to be male, although abuse by women does occur. In around a quarter of cases, the perpetrator is under 18. CSA in the family is rarely an isolated occurrence and may go on for many years (McNeish & Scott, 2018).”

Impact of CSA

CSA is an underlying issue in a range of childhood and adult problems. The damage it causes often goes unrecognised and unidentified until later in a CSA victim’s life. The impact of CSA is increasingly recognised as a critical factor in childhood and adult problems including: eating disorders, low self-esteem, difficulties at school, addictions and substance abuse, deliberate self-harm, depression, mental illness and suicide. The experience of CSA also makes a victim vulnerable to further victimisation, and can lead to offending against the next generation in the family.

While only some victims of CSA will go on to become offenders themselves, most child sexual offenders have been victims of sexual abuse and violence in their childhood (Cashmore & Shackel, 2013; Ogloff et al., 2012). Some of the research looks at the adverse outcomes of early childhood sexual abuse, exposure to violence, and neglect. These span the lifetime of individuals affecting physical and mental health, relationship difficulties and suicidality (Cashmore & Shackel, 2013; McNeish et al., 2018; Ogloff et al., 2012).

Psychologists need to be informed about the latest CSA research. The CSA Centre in the UK offers information from the research on intrafamilial CSA, giving clear, up-to-date information along with the latest research, supporting confident provision of the best possible responses to child sexual abuse (csacentre.org.uk).

From victim to offender

Considerable attention has been paid to the damage that occurs to CSA victims over time. Less focus, however, has been placed on the risk of subsequent offending and victimisation by CSA victims themselves.

Professor James Ogloff co-authored a longitudinal study in Victoria, looking at repeat victimisation and offending cycles (2012). Ogloff’s study assessed data from 2759 Victorian forensic medical records (2201 females, 558 males) who were sexually abused between 1964 and 1995 and while under the age of 16 (M=10.22; SD=4.44).

These case records were compared with criminal offence and victimisation information, and coronial databases up to 44 years later. The research showed that boys and girls who were abused were at increased risk of future offending and further victimisation when compared with children who were not victims of CSA. The results found that 1 in 10 boys who were sexually abused after the age of 12 went on to be convicted of a sexual offence as an adult. The study has been important in the field and has implications for policy and the critical need for early identification, treatment and interventions for victims of CSA.

Treatment for families

Families often hit a crisis point when intrafamilial CSA is reported to the authorities. Assistance for families and intervention should be provided as soon as possible after disclosure. Early treatment of children who have experienced this form of abuse is essential to avoid the long-term effects of CSA. Offering a therapeutic service independent of a criminal justice system response may also help offenders to seek help and seek it sooner.

Much abuse in the family remains undisclosed. Children may fear their abuser, not want their abuser to get into trouble, feel that the abuse was ‘their fault’, and feel responsible for what will happen to their family if they tell. Abuse by a family member may be particularly traumatic because it involves high levels of betrayal, stigma and secrecy (CSA Centre). Offenders should be treated at the same time as the victims. Adults must take responsibility for their offending so children who have been abused can be free of feeling that they are to blame for the offending. It is also argued by some that treating the child without also treating the offender may increase the tendency for a victim to self-blame, which is one of the adverse impacts of being abused.

Another beneficial part of treating offenders when other family members are also treated is that it allows for more objective evaluation of offenders’ responses and progress within a treatment program. Treating victims and adult offenders is a key part of breaking the cycle of CSA. Similarly, healing the impact CSA has on all members of a family can cut across generational sequences of victimisation and offending (Thornton et al., 2008).

Support from non-abusing family members is essential, not only for the emotional wellbeing of the victims, but to facilitate disclosure and give support during any investigation and legal processes. The right psychological support for victims also has positive outcomes, but the access and availability of these services can be patchy. Both adult survivors and children/young people value services that listen to, believe and respect them; where professionals are trustworthy, authentic, optimistic and encouraging, show care and compassion, facilitate choice, control and safety, and provide advocacy (CSA Centre).

Best interests of the child

It is important to remember that all engagement with the issue of CSA should be guided by the principle of what’s in the best interests of the child. The best interests of each child are not always easily recognised, and we need to ask the following questions:

• How do we measure what is in the best interest of this child?
• How do we protect this child from abuse or further abuse?
• How do we address and heal the trauma of this child?
• How do we restore (or establish for the first time) healthy relationships for this child?
• What does meaningful consultation represent for this child?

Answers will be different for each child depending on their age and circumstances.

Mandatory reporting and confidential space

In 2021, there are different mandatory reporting requirements in each state and territory. Psychologists need to inform themselves of their local legislative requirements. The APS Ethical Guidelines for reporting abuse and neglect and criminal activity (bit.ly/36HO6Ua) is a useful resource to help develop ethical frameworks for practice.

Therapists can assist victims to have confidential space and support to formulate their own ‘enabled reporting’ in their own time and pace. As they are the primary witnesses to the offending that has occurred, it is important not to undermine their personal power and willingness to provide evidence in a way that damages their adjustment or leads to retractions or acquittals, which produce further disempowerment and trauma (see Daniels & Jenkins, 2000).

Treatment as prevention

Psychologists and psychology researchers have much to offer the community in the way of treatment of CSA. Accepting a treatment approach to CSA offending takes political courage. Understandable feelings of anger and resentment from the public about how little has been done for victims, and the cover-ups that have come to light regarding CSA in institutions such as welfare homes, churches, scouts and the military (though institutional examples represent only 5–10% of such offending), have all taken the media spotlight.

As psychologists, we recognise that because CSA is an underlying cause of so many problems in life, providing treatment for CSA can also help prevent suicide, relationship difficulties and mental illness. This benefits the whole community.

If we take a truly preventative approach, we need to broaden our understanding of the issue and expand our range of responses. In addition to the criminal justice system, a well-rounded therapeutic response is needed. We need more pathways offering the hope of healing for CSA victims, and more programs to prevent offending by those at risk.

Many psychologists work with adult survivors of child sexual abuse and the article by Mark Griffiths in this issue offers a psychologist’s insight after many years of practice in this area. Recently, too, there has been signs of hope for a new approach to child sexual abuse and paedophilia. The Dunkelfeld Project in Germany is an outstanding example of prevention and is forging a pathway Australia could follow if we can harness the political will and support of psychologists (and other allied health and medical practitioners) to offer intervention for individuals before they offend against children.

Evidence-based practice and practice-informed research

As well as an emphasis on evidence- based practice, there is a greater need for practice-informed research that derives research questions from the practice of psychologists in this area. As psychologists, we must try to address some of the bigger questions in this field: Is CSA treatable? For victims? For offenders? How can we address it and prevent harm? How can we heal and support victims? Few psychology courses cover these questions thoroughly.

Most psychologists start learning about CSA when on a work placement in child protection, mental health services, prisons or private practice, where they are suddenly confronted with CSA in their clients’ lives. In addition to better training at university, there should be more opportunities for psychologists to engage in professional development, and for sharing their experience and expertise. Membership of the APS Child Sexual Abuse and Psychology Interest Group is a good way to share experiences nationwide between psychologists with varying years of involvement in different aspects of the work.

Breaking the cycle of CSA

If CSA is an intergenerational problem and, if untreated, victims go on to be at risk of further victimisation or offending, then breaking the cycle of intergenerational and intrafamilial abuse is crucial to stopping it.

Punitive measures, while important, do not treat and/or stop the problem in terms of prevention. Measures imposed by the justice system need to work in conjunction with other protective and preventative processes so as not to drive the problem even further underground by inhibiting disclosures by family members.

A public health approach, in which treatment is made readily available to all individuals who express a need for help has much to offer, whether this help is for those who experience childhood abuse or for those who fear they may offend against children.

The problem of CSA has existed in society for generations, but to date, not enough has been done to find out why it happens and what the contributing factors are. This special issue of InPsych exploring research, policy and practitioner insights, encourages all of the psychological community to work together with new vigour to address this important concern.

Contact the author: [email protected]